How is incontinence treated?

Behavioral Remedies: Bladder Retraining and
Kegel Exercises

By looking at your bladder diary, the doctor may see a pattern and suggest
making it a point to use the bathroom at regular timed intervals, a habit called
timed voiding. As you gain control, you can extend the time between scheduled
trips to the bathroom. Behavioral treatment also includes Kegel exercises to
strengthen the muscles that help hold in urine.

How do you do Kegel exercises?

The first step is to find the right muscles. One way to find them is to
imagine that you are sitting on a marble and want to pick up the marble with
your vagina. Imagine sucking or drawing the marble into your vagina.

Try not to squeeze other muscles at the same time. Be careful not to tighten
your stomach, legs, or buttocks. Squeezing the wrong muscles can put more
pressure on your bladder control muscles. Just squeeze the pelvic muscles. Don't
hold your breath. Do not practice while urinating.

Repeat, but don't overdo it. At first, find a quiet spot to practice-your
bathroom or bedroom-so you can concentrate. Pull in the pelvic muscles and hold
for a count of three. Then relax for a count of three. Work up to three sets of
10 repeats. Start doing your pelvic muscle exercises lying down. This is the
easiest position to do them in because the muscles do not need to work against
gravity. When your muscles get stronger, do your exercises sitting or standing.
Working against gravity is like adding more weight.

Be patient. Don't give up. It takes just 5 minutes a day. You may not feel
your bladder control improve for 3 to 6 weeks. Still, most people do notice an
improvement after a few weeks.

Some people with nerve damage cannot tell whether they are doing Kegel
exercises correctly. If you are not sure, ask your doctor or nurse to examine
you while you try to do them. If it turns out that you are not squeezing the
right muscles, you may still be able to learn proper Kegel exercises by doing
special training with biofeedback, electrical stimulation, or both.

If you have an overactive bladder, your doctor may prescribe a medicine to
block the nerve signals that cause frequent urination and urgency.

Several medicines from a class of drugs called anticholinergics can help
relax bladder muscles and prevent bladder spasms. Their most common side effect
is dry mouth, although larger doses may cause blurred vision, constipation, a
faster heartbeat, and flushing. Other side effects include drowsiness,
confusion, or memory loss. If you have glaucoma, ask your ophthalmologist if
these drugs are safe for you.

Some medicines can affect the nerves and muscles of the urinary tract in
different ways. Pills to treat swelling (edema) or high blood pressure may
increase your urine output and contribute to bladder control problems. Talk with
your doctor; you may find that taking an alternative to a medicine you already
take may solve the problem without adding another prescription.

Scientists are studying other drugs and injections that have not yet received
U.S. Food and Drug Administration (FDA) approval for incontinence to see if they
are effective treatments for people who were unsuccessful with behavioral
therapy or pills.

Biofeedback

Biofeedback uses measuring devices to help you become aware of your body's
functioning. By using electronic devices or diaries to track when your bladder
and urethral muscles contract, you can gain control over these muscles.
Biofeedback can supplement pelvic muscle exercises and electrical stimulation to
relieve stress and urge incontinence.

Neuromodulation

For urge incontinence not responding to behavioral treatments or drugs,
stimulation of nerves to the bladder leaving the spine can be effective in some
patients. Neuromodulation is the name of this therapy. The FDA has approved a
device called InterStim for this purpose. Your doctor will need to test to
determine if this device would be helpful to you. The doctor applies an external
stimulator to determine if neuromodulation works in you. If you have a 50
percent reduction in symptoms, a surgeon will implant the device. Although
neuromodulation can be effective, it is not for everyone. The therapy is
expensive, involving surgery with possible surgical revisions and replacement.

Vaginal Devices for Stress Incontinence

One of the reasons for stress incontinence may be weak pelvic muscles, the
muscles that hold the bladder in place and hold urine inside. A pessary is a
stiff ring that a doctor or nurse inserts into the vagina, where it presses
against the wall of the vagina and the nearby urethra. The pressure helps
reposition the urethra, leading to less stress leakage. If you use a pessary,
you should watch for possible vaginal and urinary tract infections and see your
doctor regularly.

Injections for Stress Incontinence

A variety of bulking agents, such as collagen and carbon spheres, are
available for injection near the urinary sphincter. The doctor injects the
bulking agent into tissues around the bladder neck and urethra to make the
tissues thicker and close the bladder opening to reduce stress incontinence.
After using local anesthesia or sedation, a doctor can inject the material in
about half an hour. Over time, the body may slowly eliminate certain bulking
agents, so you will need repeat injections. Before you receive an injection, a
doctor may perform a skin test to determine whether you could have an allergic
reaction to the material. Scientists are testing newer agents, including your
own muscle cells, to see if they are effective in treating stress incontinence.
Your doctor will discuss which bulking agent may be best for you.

Surgery for Stress Incontinence

In some women, the bladder can move out of its normal position, especially
following childbirth. Surgeons have developed different techniques for
supporting the bladder back to its normal position. The three main types of
surgery are retropubic suspension and two types of sling procedures.

Retropubic suspension uses surgical threads called sutures to support the
bladder neck. The most common retropubic suspension procedure is called the
Burch procedure. In this operation, the surgeon makes an incision in the abdomen
a few inches below the navel and then secures the threads to strong ligaments
within the pelvis to support the urethral sphincter. This common procedure is
often done at the time of an abdominal procedure such as a hysterectomy.

Sling procedures are performed through a vaginal incision. The traditional
sling procedure uses a strip of your own tissue called fascia to cradle the
bladder neck. Some slings may consist of natural tissue or man-made material.
The surgeon attaches both ends of the sling to the pubic bone or ties them in
front of the abdomen just above the pubic bone.

Midurethral slings are newer procedures that you can have on an outpatient
basis. These procedures use synthetic mesh materials that the surgeon places
midway along the urethra. The two general types of midurethral slings are
retropubic slings, such as the transvaginal tapes (TVT), and transobturator
slings (TOT). The surgeon makes small incisions behind the pubic bone or just by
the sides of the vaginal opening as well as a small incision in the vagina. The
surgeon uses specially designed needles to position a synthetic tape under the
urethra. The surgeon pulls the ends of the tape through the incisions and
adjusts them to provide the right amount of support to the urethra.

If you have pelvic prolapse, your surgeon may recommend an anti-incontinence
procedure with a prolapse repair and possibly a hysterectomy.

Figure 4. Side view. Supporting sutures in place following retropubic or
transvaginal suspension (left). Sling in place, secured to the pubic bone
(center). The ends of the transobturator tape supporting the urethra are pulled
through incisions in the groin to achieve the right amount of support (right).
The tape ends are removed when the incisions are closed.

Recent women's health studies performed with the Urinary Incontinence
Treatment Network (UITN) compared the suspension and sling procedures and found
that, 2 years after surgery, about two-thirds of women with a sling and about
half of women with a suspension were cured of stress incontinence. Women with a
sling, however, had more urinary tract infections, voiding problems, and urge
incontinence than women with a suspension. Overall, 86 percent of women with a
sling and 78 percent of women with a suspension said they were satisfied with
their results. Women who are interested in joining a study for urinary incontinence can go to
www.ClinicalTrials.gov for a list of
current studies recruiting patients.

Talk with your doctor about whether surgery will help your condition and what
type of surgery is best for you. The procedure you choose may depend on your own
preferences or on your surgeon's experience. Ask what you should expect after
the procedure. You may also wish to talk with someone who has recently had the
procedure. Surgeons have described more than 200 procedures for stress
incontinence, so no single surgery stands out as best.

Catheterization

If you are incontinent because your bladder never empties completely-overflow
incontinence-or your bladder cannot empty because of poor muscle tone, past
surgery, or spinal cord injury, you might use a catheter to empty your bladder.
A catheter is a tube that you can learn to insert through the urethra into the
bladder to drain urine. You may use a catheter once in a while or on a constant
basis, in which case the tube connects to a bag that you can attach to your leg.
If you use an indwelling-long-term-catheter, you should watch for possible
urinary tract infections.

Other Helpful Hints

Many women manage urinary incontinence with menstrual pads that catch slight
leakage during activities such as exercising. Also, many people find they can
reduce incontinence by restricting certain liquids, such as coffee, tea, and
alcohol.

Finally, many women are afraid to mention their problem. They may have
urinary incontinence that can improve with treatment but remain silent sufferers
and resort to wearing absorbent undergarments, or diapers. This practice is
unfortunate, because diapering can lead to diminished self-esteem, as well as
skin irritation and sores. If you are relying on diapers to manage your
incontinence, you and your family should discuss with your doctor the possible
effectiveness of treatments such as timed voiding and pelvic muscle exercises.